Pure Dermatology, PLLC

Thank you for choosing Pure Dermatology for your dermatological care.

FINANCIAL POLICIES:

Insurance: Pure Dermatology, PLLC, located at 501 S Cherry Street, Suite 310, Glendale, CO 80246 accepts most major insurance carriers. It is your responsibility to check with your insurance carrier regarding your plan’s benefits and coverage.You are financially responsible for copays, deductibles, coinsurance, amounts in excess of insurance benefits, and any non-covered services. If coverage is denied, you give Pure Dermatology permission to appeal to your insurance carrier on your behalf. If you are uninsured, out of network, or have a plan that we are not contracted with, you will be considered self-pay and payment is due at the time of service.

  • Copays: copays are due at the time of service. You agree to assign payment from your insurance to Pure Dermatology, PLLC. You are financially responsible to Pure Dermatology, PLLC for the charges above your copay and not paid by insurance and understand that those charges are due within 30 days of receiving the statement.
  • Referrals: You are responsible for all referrals/authorizations required to comply with your insurance plan. When required, you must obtain a referral prior to your scheduled appointment. If your claims are denied for lack of referral or your referral is rejected by your insurance company, it is possible that you may not be able to be seen at Pure Dermatology. In some cases, you may have the option to pay out of pocket on the day of service and will be responsible for all charges incurred.

Laboratory Services: Some services, such as biopsies, surgery, and cultures require specimens to be sent to an outside lab for processing. You will receive a separate bill from Pathology or Laboratory Services. The patient is responsible for payment of all laboratory services not covered by insurance.

Self Pay or Uninsured: If you are uninsured, out of network, or have a plan that we are not contracted with, you will be considered self-pay and payment is due at the time of service.

Cosmetic or Non-Covered Services: Some services we provide are cosmetic in nature and/or may be deemed not medically necessary by your insurance carrier or not a covered benefit by your specific policy and therefore not paid by your insurance. All of these charges are due at the time of service.

Credit Card on File: A credit card will be kept on file for all balances due.

Cancellation Policy: We request cancelations or rescheduling at least 24 hours in advance of scheduled appointments. Changes less than 24 hours in advance or failure to show up for a scheduled appointment will result in a $50.00 fee.

Deposits: Surgical or cosmetic procedures may require a deposit at the time of scheduling. The deposit will be non refundable if the patient fails to show up or if the appointment is changed or cancelled less than 24 hours prior to the scheduled procedure.

Medical Records Request: Current patients may obtain a copy of their medical records on the Pure Dermatology patient portal at no cost. Other medical record requests will be charged a $20 fee.

Billing Office Contact: Pure Dermatology utilizes an outside billing company, RPM Medical Billing. RPM may be reached at 303-791-1987. Please contact RPM regarding any billing concerns.

PATIENT AUTHORIZATIONS:

Authorization for Treatment:

  • I hereby voluntarily agree to diagnostic procedure(s) and medical treatment(s) which may be administered or performed on the patient listed below, under the general or specific instructions of the physician, or the physician’s designee(s). I further understand that the practice of medicine is not an exact science and that the diagnosis and treatment may involve risks. No guarantees have been made to me as to the result of the treatment at this office.

Authorization for Release of Information:

  • I understand the Pure Dermatology, PLLC will disclose any diagnosis and pertinent information to the extent required to assure payment from insurance companies. I understand that this disclosure, unless expressly limited by me in writing, will extend to all aspects of treatment including testing and/or treatment.

Authorization for Assignment of Benefits:

  • I hereby assign all medical and surgical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance and any other health / medical plan, to issue payment check(s) directly to Pure Dermatology, PLLC. for medical services rendered to myself and/or my dependents. I understand that I am responsible for any amount not covered by insurance.

HIPAA PRIVACY NOTIFICATION:

  • As required by law, Pure Dermatology, PLLC maintains a privacy policy dedicated to the protection of our patient’s medical information. A copy of this policy is available to view on our website and upon request at our front desk. I understand that if I have questions, I may contact Pure Dermatology to discuss my concerns. |

Name of Patient:
Signature of Patient or patient representative:
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